Introduction One of the most important aspects of forensic medicine – both clinical and pathological – is

the assessment, classification and documentation of injury. Any healthcare professional should be able
to appropriately document injury in a way that can be understood and interpreted by others. Most non-
forensic healthcare professionals will not be trained in the interpretation of injuries and wound
causation, but accurate documentation can greatly assist the legal process at a later stage. Offences
against individuals of a physical nature that may result in criminal prosecutions have a great variety of
types and origins, not all of which may cause visible evidence (e.g. poisoning, infection). The role of the
forensic pathologist and forensic physician is to ensure that the medical relevance of findings, or lack of
them, is understood by the investigating authority. ■ Terminology of injury Words to describe injury or
harm are used nonspecifically by lay persons and non-forensic healthcare professionals. In a legal setting
the use of the word may have a specific meaning that can influence the nature of the charge and the
penalties related to an offence. Perhaps the most frequent error is the use of the word ‘laceration’ used
in the context of a cut to the skin. In the forensic setting – as discussed below – a laceration is a split or
tear in the skin caused by blunt impact. If the word laceration is used wrongly to described a cut caused
by a knife (an incised wound) this may have implications with regard to the credibility of the witnesses.
Every jurisdiction will have its own legal classification of injury or wounding, and again the use of such
terms may have specific relevance. Forensic practitioners must be familiar with such classifications in
order to assist the courts in determining the seriousness of an injury. ■ ■ Introduction Terminology of
injury 8 ■ Law of injury ■ Types of injury ■ Other types of injury pattern ■ Survival after injury ■ Self-
inflicted injury ■ Torture ■ Documentation of injury or marks of injury ■ Further information sources
Assessment, classification and documentation of injury 77 Types of injury Most harm or injury can be
embraced by one of the following broad groups, using terms used within the England and Wales
jurisdiction: ■ Those with a fatal outcome • Murder • Manslaughter ■ Those without a fatal outcome •
Assault, assault occasioning actual bodily harm • Common assault • Battery, or common battery •
Wounding or wounding with intent • Poisoning • Inflicting grievous bodily harm or causing grievous
bodily harm with intent ■ Sexual offences (see Chapter 12) • Penetrative • Non-penetrative (both with
or without extragenital injury). ■ Law of injury In the England and Wales setting a ‘wound’ (used by most
people interchangeably with ‘injury’) can have a specific legal meaning. In the legal context, a wound is
an injury that breaks the continuity of the skin. There must be a division of the whole skin structure and
not merely a division of the cuticle or upper layer. As the skin is not broken, a bruise or internal
rupturing of blood vessels is not a wound. A broken bone is not considered a wound, unless it is a
comminuted fracture. The Offences against the Person Act 1861 (‘the Act’), which has been amended
over the years, sets out a range of offences for which an individual, in England and Wales, can be
prosecuted when that individual is alleged to have caused injury to another person. This statute
excludes homicide and sexual offences (which are covered by the Sexual Offences Act 2003). As may be
expected the terminology used in a law whose origins go back almost one and half centuries can
sometimes be a little unclear. The main offences relevant to injury assessment by forensic practitioners
are found in the following sections of the Offences Against the Person Act. Section 18 This section
creates the offences of wounding and causing grievous bodily harm, with intent to cause grievous bodily
harm, or to resist arrest. It is punishable with life imprisonment, the specific wording being Whosoever
shall unlawfully and maliciously by any means whatsoever wound or cause any grievous bodily harm to
any person ... with intent ... to do some ... grievous bodily harm to any person, or with intent to resist or
prevent the lawful apprehension or detainer of any person, shall be guilty of felony, and being convicted
thereof shall be liable ... to be kept in penal servitude for life ... . The key element of this offence is
intent. Types of injury would include stabbings or shootings. Section 20 This section creates the offences
of wounding and inflicting grievous bodily harm. They are less serious than the offences created by
Section 18 and carry a maximum prison sentence of 5 years. The key element of this offence is the
causing of grievous bodily harm, but without the intent to do so. Section 47 This section creates the
offence of assault occasioning actual bodily harm. It encompasses those assaults that result in
substantial injuries, typically requiring a degree of medical treatment for the victim and provides the
penalty to which a person is liable on conviction of that offence on indictment. A periorbital haematoma
with a superficial laceration after a punch, or a broken tooth, are the types of injury that may be
considered a Section 47 assault. ■ Types of injury Injury caused by the application of physical force can
be divided into two main groups: blunt force and sharp force. There are a number of other types of
injury caused by non-physical forces, which can be thermal, chemical, electrical or electromagnetic
which are referred to in other Chapters. Blunt-force injury Blunt-force trauma is that trauma not caused
by instruments, objects or implements with cutting edges. The nature of the force applied may include
blows (impacts), 78 8 Assessment, classification and documentation of injury traction, torsion and
oblique or shearing forces. Bluntforce trauma may have a number of outcomes: ■ no injury ■
tenderness ■ pain ■ reddening (erythema; Figure 8.1) ■ swelling (oedema; Figure 8.2) ■ bruising
(contusion; Figure 8.3) ■ abrasions (grazes; Figure 8.4) ■ lacerations (Figure 8.5) ■ fractures (Figure 8.6).
Blunt impact injuries can be described (in terms of force applied) as being weak (for example a ‘gentle’
(b) (a) Figure 8.3 Bruising (contusion) to thigh (a) following direct blunt force impact (fall between iron
girders). (b) Shows resolution of bruising 5 days after injury as seen in 8.3(a). (c) Bruising to leg from
multiple blunt impacts with a piece of wood. (c) Figure 8.1 Reddening (erythema) related to blunt
impact at outer aspect of left eye. Figure 8.2 Marked swelling (oedema) following multiple punches to
left side of face. 79 Types of injury slap on the face), weak/moderate, moderate, moderate/severe or
severe (for example a full punch as hard as possible). The more forceful the impact the more likely that
visible marks will be evident. Tenderness is pain or discomfort experienced on palpation by another of
an area of injury. Both pain and tenderness are subjective findings and are thus dependent on (1) the
pain threshold of the individual and (2) their truthfulness. The other features of blunt-force injury are
visible effects of contact. Reddening describes increased blood flow to areas that have been subject to
trauma, but not to the extent that the underlying blood vessels are disrupted. Reddening must be
distinguished from red bruises by its ability to blanch from finger pressure. Bruises Bruises are
discoloration of skin surface caused by leakage of blood into underlying tissues from damaged blood
vessels. Two events must occur before a bruise can form: damage to a blood vessel (usually small-calibre
blood vessels such as veins and arterioles) from which blood leaks, and the leakage of that blood into
surrounding tissues. Bruising is most commonly seen in the skin, but it can also occur in the deeper
tissues, including muscle and internal organs. The extent of damage to the blood vessels is generally
proportionate to the force applied: the greater the force, the more blood vessels are damaged, the
greater the leakage of blood and the bigger the bruise. (a) (b) Figure 8.4 (a) Variable depth abrasions
(grazes) caused by impact against concrete surface. (b) Linear abrasions caused by fi ngernail scratching
on torso. Figure 8.6 Hand with abrasions, swelling, reddening and underlying fracture of 5th metacarpal
caused by repeated punching of cell door. Figure 8.5 Laceration, with irregular edges, maceration and
skin bridging caused by direct impact to forehead with wooden pole. 80 8 Assessment, classification and
documentation of injury Once outside the confines of the blood vessel, blood is broken down, resulting
in the various colour changes seen. Eventually, all of the blood is removed and the overlying skin returns
to its normal colour. Bruises are one of the areas where a number of terms have been used in the past,
which complicate the understanding of their nature. The term ‘ecchymosis’ has been used for specific
types of bruise but should not now be used as it does not assist in understanding the type or mechanism
of injury. Bruising is best used to describe visible external marks caused by leakage of blood into skin
and subcutaneous tissues, while contusion can be used for leakage of blood into tissues in body cavities.
The term ‘haematoma’ can be used to refer to a palpable collection of blood under the skin (and one
which, if a needle aspiration were to be undertaken, would show liquid blood in a cavity). ‘Petechiae’ are
small bruises, often described as ‘pin-point haemorrhages’, that have been said to be < 2 mm in size.
However, that is an arbitrary figure and, like all bruises, petechiae can develop and evolve and coalesce,
and the use of a rigid size measurement is inappropriate (Figure 8.7). Direct blunt force, in addition to
unambiguous impacts such as strikes with fists, kicks or weapons, also includes mechanisms such as
poking, squeezing and gripping. Indirect blunt force may be represented by suction (as in ‘love bites’;
Figure 8.8) or following compression. Compression may produce petechiae at the level of or above the
compressing force (e.g. in ligature strangulation). Bruises evolve and can ‘migrate’. Gravity and tissue
planes are two of the factors that may determine how the appearance of a bruise might change (Figure
8.9). Thus the presence of a bruise at a particular site does not necessarily imply that the blunt impact
was applied at that site. Some very superficial bruises (often called intradermal bruises), caused by
leakage of blood confined to the epidermis and the upper strata of the dermis, can remain in the
position in which the impact occurred, and ‘patterned’ bruises, which reproduce the nature of the object
that caused them, often have such an ‘intradermal’ element. Intradermal bruises are often Figure 8.7 (a)
Close-up of face after manual strangulation 2 hours after compression with multiple petechial bruising
over facial skin. (b) Scleral blood, caused by coalescence of multiple petechiae, 36 hours after manual
strangulation. (a) (b) Figure 8.8 Classical love or ‘hickey’ bite – bruising to neck caused by suction. 81
Types of injury Figure 8.9 Extensive bruising following tissue planes and contours, one week after
multiple blunt force impacts to (a) head and (b) face (neck was spared impacts). (a) (b) associated with
diffuse compression forces such as pressure from a car tyre or from a shoe during a stamp or a kick
(Figure 8.10). Certain types of blunt injury commonly cause evidentially useful patterns. Single patterned
bruises may indicate the nature of the impacting object. ‘Tramline’ bruises (Figure 8.11) are those
caused by impacts from longitudinal, generally cylindrical Figure 8.10 (a) Patterned bruise – intradermal
bruising caused by stamping on back with textured clothing intervening. (b) Patterned bruise caused by
impact of dog chain. (c) Patterned bruise (bruise obliquely towards midline) caused by impact of 2 × 2
length of wood. (a) (b) (c) 82 8 Assessment, classification and documentation of injury or rod-like,
objects (where blood is forced laterally from the point of impact, rupturing blood vessels either side of
the impacting object) and footprint imprint bruises may be seen from stamp injuries (Figure 8.12).
Patterns of a number of bruises may also help corroborate the nature of the causative force. For
example a row of four 1–2 cm oval or round bruises may be caused by the impact of knuckles in a
punch; groups of small oval or round bruises are also indicative of fingertip pressure, as in gripping, and
there is sometimes a single, larger, thumb bruise on the opposite side of the limb (Figure 8.13). Fingertip
bruises on the neck or along the jaw line are commonly seen in manual strangulation. Examination of
injuries must be undertaken in good light and, in the case of bruises, such is required in order to ensure
that small or subtle skin colour changes are not missed. Even with darker skin tones, a proper
examination will be able to identify areas of bruising. Age estimation based on the colour of bruising is
not now considered appropriate, with one exception – a yellow-coloured bruise may be more than
Figure 8.12 Shoeprint bruise following stamping injury to face. 18 hours old. The colouring must not be
taken from Figure 8.13 Grip marks from fi ngers on assailant bruises from grip and abrasions from fi
ngernails seen on upper inner arm. Figure 8.11 Tramline bruise caused by impact from cylindrical fi rm
object (in this case, a police baton). 83 Types of injury photographic images where colour reproduction
may be inaccurate and it must also be understood that the perception of yellow colour may be
influenced by the visual capability of the viewer, interobserver variation and underlying skin tone.
Studies in children suggest that estimation of ageing of bruising cannot be achieved by colour
interpretation, and this principle generally applies to adults also. Bruising can occur after death: blood
vessels are just as easily damaged by the application of force and, provided that there is blood with
some pressure within those vessels, bruising can occur. Such pressure may exist at the lowermost
vessels because of the static weight of the column of blood. Post-mortem bruises are generally small
and lie on the dependent parts of the body. Bruising may also be found in areas of post-mortem
dissection and care must be taken in interpreting ‘new’ bruises when an autopsy has been performed.
Abrasions An abrasion or graze is a superficial injury involving (generally) outer layers of skin without
penetration of the full thickness of the epidermis. They are caused when there is contact between a
rough surface and the skin, often involving a tangential ‘shearing’ force (Figure 8.14). They can also be
caused by crushing of the skin when the force is applied vertically down onto the skin. Bite marks and
the grooved, and often parchmented, abrasion found in hanging, can cause typical ‘crush’ abrasions
(Figure 8.15). The appearance of abrasions will allow a determination of the exact point of contact and
may assist in determining the direction of the impact. Specific types of abrasions include scratches
(linear abrasions, e.g. caused by fingernails; Figure 8.16), scuff (brush) abrasions (very superficial
abrasions, Figure 8.17) and point or gouge abrasions (deeper linear abrasions caused by objects such as
metal nails; Figure 8.18). As the epidermis does not contain blood vessels, superficial abrasions might
not bleed, but the folded nature of the junction between the dermis and the epidermis, and the
presence of loops of blood vessels in the dermal folds, will mean that deep abrasions have a typical
punctate or spotty appearance. Deeper abrasions may therefore bleed, resulting in subsequent scabbing
and possible scarring. The size, shape and type of abrasion depends upon the nature of the surface of
the object which contacts the skin, its shape and the angle at which contact is made. Contact with the
squared corner of an object (e.g. a brick) may well result in a linear abrasion, whereas contact with a
side of the same object will cause a larger area of ‘brush’ abrasion. Contact with a rough surface, such as
a road, especially when associated with the higher levels of force found in traffic accidents, will result in
areas of ‘gravel rash’, sometimes called ‘brush’ abrasions (Figure 8.19). Figure 8.14 Abrasion to right face
and cheek caused by kick from shod foot. Linearity of abrasion assists in determining direction of
movement. Figure 8.15 Ligature mark with parchmented abrasion in posterior part of neck. 84 8
Assessment, classification and documentation of injury Tangential contact with a relatively smooth
surface may well result in such fine, closely associated, linear abrasions that the skin may simply appear
reddened and roughened. This may be termed a ‘friction burn’; close inspection will reveal the true
nature of the wound. The direction of the causative force can be identified by close inspection of the
injury (magnification of a high-resolution digital image can be useful when changes are subtle) and
identifying the torn fragments of the epidermis which are pushed towards the furthest (distal) end of
the abrasion (Figure 8.20). Figure 8.18 Deep linear point or gouge abrasions to forehead. Figure 8.17
Close-up showing tags of elevated skin in scuff abrasions. (a) (b) Figure 8.16a (a) Multiple fi ngernail
scratches with wheal reaction and superfi cial abrasions. (b) Deeper abrasions caused by fi ngernails.
Figure 8.19 Deep and extensive abrasion (‘gravel rash’) caused by contact with road surface after
motorcycle accident. 85 Types of injury Crush abrasions – often associated with ‘intradermal’ bruising –
are important because they may retain the pattern of the causative object. Diagrams and sketches can
be extremely useful and scaled photographs should be taken in order to allow subsequent comparison
to be made between the injury and a ‘suspect injury-causing implement of surface’. Many different
objects have been identified in this way, such as car radiator grills, the tread of escalator steps, plaited
whips and the lines from floor tiles. Lacerations Lacerations appear as ‘cuts, splits or tears’ in the skin
and are the result of a blunt force compressing or stretching the skin; they may extend through the full
thickness of the skin and can bleed profusely. Because the skin is composed of many different tissue
types, some of the more resilient tissues will not be damaged by the forces that split the weaker tissues.
Those most resilient tissues are often nerves, fibrous bands of fascial planes and, sometimes, at the base
of the laceration, an occasional medium-sized elastic blood vessel. These structures are seen to extend
across the defect in the skin and are often referred to as ‘bridging fibres’. The same blunt force causing
such a laceration may also cause irregular splits, bruising and abrasion at the margins of the wound
(Figure 8.21). Lacerations are most common where the skin can be compressed between the applied
force and underlying bone (i.e. over the scalp, face, elbows, knees, shins, etc.). They are rare (unless
severe force has been applied) over the soft, fleshy areas of the body such as the buttocks, breasts and
abdomen. When significant tangential blunt force is applied to the skin, for example owing to the rolling
or grinding action of a vehicle wheel, the laceration may be horizontal and result in a large area of
separation of skin from the underlying tissues (often called ‘flaying’ or ‘degloving’). The margins of a
laceration are usually ragged; however, if a thin, regular, object inflicts an injury over a bony area of the
body, the wound caused may look very sharply defined and can be mistaken for an incised injury.
Careful inspection of the margins will reveal some crushing and bruising, and examination of the inner
surfaces of the wound will reveal the presence of bridging fibres. The shape of the laceration (e.g. linear,
curvilinear or stellate) rarely reflects the nature of the Figure 8.21 Laceration to ear following impact
with baseball bat – note irregularity of laceration and associated swelling bruising masked by dry blood.
Figure 8.20 Directional scuff – note raised skin layers on left side of abrasion: arrow indicates direction of
abrasive movement. 86 8 Assessment, classification and documentation of injury impacting object
(unless accompanied by other patterned blunt-force injury). Sharp-force injury Injuries caused by sharp
force need to be distinguished from blunt-force injuries such as lacerations or gouge and point
abrasions. In general, sharp-force injuries have cleanly divided, distinct wound edges, which may span
irregular surfaces, and penetrate different types of tissue with the same contact (Figure 8.22). Incised
and slash wounds Incised wounds are caused by objects with a sharp or cutting edge, most commonly a
knife but examples include an axe, shards of glass, broken glasses and bottles, an edge of broken
pottery, a piece of metal, can also cause these wounds (Figure 8.23). An incised injury is distinguished
from a stab wound by being longer on the skin surface than it is deep. A surgical operation wound is an
example of an incised wound. Incised wounds caused by sharp implements moving across skin surface
during an assault may sometimes be called ‘slash’ wounds (Figure 8.24). The edges of the wound will
give some indication as to the sharpness of the weapon causing it. A sharp edge will leave no bruising or
abrasion of the wound margins. Careful inspection of the depths of the wound will reveal that no
bridging fibres are present because the cutting edge divides everything in its passage through the skin.
Incised wounds, by their nature, are only lifethreatening if they penetrate deeply enough to damage a
blood vessel of significant size. Thus, incised wounds over the wrist or neck, where major arteries lie in
more superficial tissues, can prove fatal. Stab wounds A stab wound is caused by a sharp implement and
is deeper than it is long on the skin surface. A stab wound can, however, be created but it’s progress into
the body be impeded by bone, in which case the depth may not exceed wound width. This classification
of such a wound is relatively straightforward in the deceased, but in the living (1) depth may not be
assessed at all and (2) if it is, the measurement may be inaccurate. Forensic pathologists may also have
the advantage of being able to determine direction of such wounds. The direction or depth of a wound
may not be clear when interpreting medical or operative note in survivors of stab injury. Depth of the
injury and the direction are of great importance when considering different accounts of causation of
stab wounds and so the more information recorded at the time of treatment, the more helpful it can be
to the justice system. Any weapon with a point or tip can cause a stab wound; the edge of the blade
does not need to be sharp. Stab-like wounds may also be caused by (relatively) blunt objects such as
screwdrivers or car keys. For penetration of the body to occur, a variety (a) (b) Figure 8.22 (a) Sutured
incised wound caused by razor blade – note how wound follows contours. (b) Incised wound caused by
knife drawn across surface of fi ngers in this case contours are spared. 87 Types of injury of factors
determine how much force is required, including: ■ the sharpness of the tip of the weapon: this is often
the most important factor and the sharper the tip, the easier it is to penetrate the skin ■ the sharpness
of the ‘cutting edge’ of the implement ■ the nature of the force applied: stabbing incidents are usually
dynamic, involving complex relative movements between victim and assailant ■ whether clothing has
been penetrated: some items of clothing, such as thick leather jackets, may offer significant resistance
to penetration. ■ whether bone has been injured: skin offers very little resistance to penetration by a
sharp knife, but injury to bone tends to suggest that a greater force has been used to inflict the wound.
Significant penetration of bone may also damage the knife. (c) (d) Figure 8.23 (a) Sutured incised wound
across right side of head and face. (b) Incised wound to neck caused by use of knife. (c) Irregular incised
wounds caused by glass impacted and breaking on face. (d) Post-treatment appearance after glassing –
note multiple small superfi cial shard cuts in association with larger incised wounds. (a) (b) 88 8
Assessment, classification and documentation of injury Once a knife or other sharp implement has
penetrated the skin, subcutaneous tissues (except bone) offer little additional resistance to deeper
penetration and, to an assailant, it may appear that the rest of the weapon ‘follows through’ with
almost no additional effort or force being applied. The insertion of a sharp knife into the body, especially
through the skin stretched across ribs, requires very little force, and pressure from a single finger may be
sufficient to push a very sharp implement through the chest wall at this site. The commonest sharp
weapon used in an assault is a knife of some sort, but a huge variety of weapons such as swords, shards
of glass and broken bottles can be used. The appearances of a stab wound on the skin surface can assist
in determining the size and the cross-sectional shape of the weapon used (Figure 8.25). If a blade of
some sort is used, the general comments in Box 8.1 apply. Chop injury Chop injuries may be caused by a
variety of implements that are generally heavy, and relatively blunt, bladed instruments. These include
some machetes, Samurai swords and axes. Because of the variability of the ‘blade’, injuries sustained
may be a mixture of sharp- and blunt-force wounds, typically involving bruised, crushed and abraded
wound margins (Figure 8.26). Fractures and amputations may also result from the use of such
implements and substantial scarring may ensue. Box 8.1 Features to consider in a possible stab wound ●
A slit-like wound will distort, after removal of the weapon, because of the action of elastic fi bres
present in the skin. If the fi bres are orientated at right angles to the skin surface wound, it will be pulled
outwards and get shorter and wider; if they run parallel to the skin surface wound, it will be pulled
lengthways and the edges will tend to close and the wound elongate slightly. ● Even if the edges of the
wound are gently pushed together, the resulting defect is rarely the exact size as the knife. ● The size of
the wound also depends on the shape/confi guration of the blade and how deeply it was inserted. ●
Movement of the knife in the wound, as a consequence of relative movement between the assailant and
victim, may cause the wound to be enlarged. If the knife is twisted or rotated within the body, an
irregularly-shaped, or even triangular, skin surface wound may be result. ● Many knives have only one
cutting edge, the other being blunt. This design may be reproduced in the wound where one wound
apex is sharp or ‘V’-shaped, while the other is blunt, or rounded. The blunt wound apex may ‘split’ at
each side, an appearance commonly referred to as a ‘fi shtail’. ● Provided that clothing has not
intervened, skin adjacent to the stab wound may be bruised and/or abraded as a consequence of
forcible contact between the skin and, for example, the hilt/blade guard of a knife, or the ‘knife-
wielding’ hand of the assailant. ● The depth of a wound within the body can be greater than the length
of the blade if a forceful stab is infl icted. This is because the abdomen and, to a lesser extent, the chest,
can be compressed by the force of the knife hilt or knife-wielding hand against the skin. ● A blunt object
such as a screwdriver or ‘spike’ will tend to indent, split and bruise the skin on penetration. Different
types of screwdriver can cause different patterns of injury, for example ‘cross-head’ or ‘Phillips’
screwdrivers can cause very distinctive cruciate skin surface wounds. ● Unusually shaped stab wounds
may be caused by implements less commonly encountered in stabbing assaults; scissors, for example,
may cause a ‘Z-shaped’ skin surface injury, while chisels may cause rectangular-shaped stab wounds.
When such injuries are encountered, it is important to consider unusual causative implements. Figure
8.25 Knife wound with knife tip in bottom right of fi gure. Figure 8.24 Slash-type wound to forearm:
wound is wider than it is deep. 89 Other types of injury pattern ■ Other types of injury pattern
Examination of the site, orientation and pattern(s) of the wounds will often reveal useful indications
about the causation of the wound. Particular actions such as punches, kicks, bites, scratching holding or
gripping injuries and defence injuries can be identified by their patterns (Figure 8.27). Punching A punch
is a blow delivered by the clenched fist. The blow can be directed anywhere, and the effects are in part
dependent on force of delivery. Visible injury is more likely to be seen over those areas of the body
where the skin is closely applied to bone, as in the face and skull. The entire range of blunt force injuries
can be caused, including bruises, abrasions, lacerations and fractures. These may also occur on the hand
delivering the punch. On the face, the lips can also be forced back onto the teeth, resulting in bruising,
abrasion and lacerations inside the lips. Any examination following a blow to the face or mouth requires
intraoral examination. A single blow to the nose or forehead can cause bilateral periorbital bruising
(black eyes). Ribs may be fractured by blows of sufficient force. Intra-abdominal injury, including
mesenteric laceration, intestinal rupture and injury to the major abdominal organs, can occur if punches
of adequate force are delivered to a vulnerable (i.e. unresisting) abdomen. Kicking and stamping Kicking
and stamping injuries are caused by feet, which may be shod or unshod. Again, as with punches, the
entire gamut of blunt force injury may be seen, but kicks and stamps can be more powerful than
punches, and more so if delivered to an individual already vulnerable (e.g. lying on the floor or
unconscious). Kicking and stamping may leave areas of intradermal bruising that reflect the pattern of
the sole of the shoe and this can lead to identification of the assailant. The victim is often on the ground
when these injuries are inflicted, and blows from the foot are commonly directed towards the head and
face, the chest and the abdomen. The high levels of force that can be applied by a foot mean that there
are often underlying skeletal injuries. These are most common in the facial skeleton and in the ribs.
Stamping injuries to the front of the abdomen may result in rupture of any of the internal organs. Bite
injuries Bite marks are commonly associated with bruising and may be associated with lacerations if
severe Figure 8.27 Typical severe fi ngernail scratching injuries to face. force is applied. Bite marks can
be seen in sexual Figure 8.26 Multiple hypertrophic scars to left arm and shoulder caused by machete.
90 8 Assessment, classification and documentation of injury assaults, child abuse and occasionally on the
sports field. A forensic odontologist should review any possible bite marks when confirmation of identity
of the biter is required. Bite marks may be found on almost any surface of the body; specific sites are
associated with specific forms of assault (Figure 8.28). The neck, breasts and shoulders are often bitten
in a sexually motivated attack, while in child abuse bites to the arms and the buttocks are common. Bites
can also be inflicted by many common inhabitants of a house, including family pets. Odontological
examination will reveal different sizes, different arch shapes and different dentition in these cases. If a
suspected bite is found at examination, a swab of the area should be taken for DNA and the bite should
be photographed with a scale. Photography should be undertaken by trained forensic photographers.
Photography using ultraviolet light may be of assistance in older cases but is often of limited value.
Defence injuries In situations of assault and attack it is a normal reflex to protect oneself. In many
instances the reflex involves sustaining injury but reducing the damaging results. When a knife or a
stabbing implement is directed at an individual, blows to the head and face may be defended by raising
the hands and arms to cover the head and face. The hand may attempt to grab or deflect a weapon. The
arms and hands sustain in juries but the head is protected. In addition, in incidents involving knives
where a knife may be thrust towards an individual the individual may try and defend themselves by
grabbing the knife blade and deflecting it away from, for example, the chest and abdomen. Grabbing of
the cutting blade will result (if the knife is sharp enough) in cuts to the part of the hand that grabs the
knife (generally the palm or gripping side of the hand and fingers; Figure 8.29). Both assailant and victim
can sustain incised wounds if there has been a struggle. In general, the dominant hand may generally
automatically be used to defend, but if the dominant hand (most commonly the right) is otherwise
engaged, the non-dominant hand may be used. Multiple defence wounds may be sustained during an
assault, and such wounds to the (c) Figure 8.28 Bites. (a) Human bite with tissue loss to right ear. (b) Bite
mark with bruising, skin lifts and teeth marks to chest. (c) Bite causing tissue loss to chin no clear teeth
marks evident. (b) (a) 91 Self-inflicted injury hands may be of variable depth, or discontinuous, as the
hand is not a flat surface. Defence-type injury after blunt weapon assault will be seen in the same
regions, namely the extensor surfaces of arm and upper arm (Figure 8.30) which may be raised to
protect against blows, and on the back, or the back of the legs, if an individual is taken to the ground
and, for example, kicked. The victim will tend to curl up in a ball with hands and arms over the head and
legs tucked up towards the chest. Defence injuries may be absent following an assault. This may be for a
number of reasons including unconsciousness from assault, or incapacity through drugs or alcohol or
restraint by another person or persons. ■ Survival after injury The length of survival following infliction
of an injury is difficult to determine: every human being is different and this variability in survival and
postinjury activity is to be expected. Any expression of either survival time or of the ability to move and
react must be given on the basis of the ‘most likely’ scenario, accepting that many different versions are
possible. The court should be advised of the difficulties of this assessment and should be encouraged
also to consider eyewitness accounts. It must be remembered that survival for a time after injury and
long-term survival are not one and the same thing. The initial response of the body to haemorrhage is
‘compensatible shock’, shutting down peripheral circulation; if blood loss continues, the homeostatic
mechanisms may be overwhelmed and the individual enters the phase of ‘uncompensated shock’, which
leads inexorably to death. Many examples exist of individuals with apparently potentially immediately
fatal wounds who have performed purposeful movements/actions for some time after the ‘fatal’ injury.
Forensic practitioners should always be very wary about allotting fixed times after which somebody
could not have survived, only to be confronted with CCTV evidence showing that they clearly did. ■ Self-
inflicted injury All types of injury can be self-inflicted, accidentally inflicted or deliberately inflicted by
another. Most deliberate self-inflicted injuries are caused by those with psychiatric or mental health
issues, or in association with stressful situations and anxiety. Patterns of injury are well-documented in
such individuals. In the forensic setting there is a small, but significant, group of individuals who self-
harm for other motivations, such as staging assault for attention-seeking and similar motives, or to
deliberately implicate others in criminal acts or for financial gain (e.g. insurance fraud). Such injuries will
not follow the pattern of ‘typical’ self-arm injury. Fatal self-inflicted blunt-force injuries may be inflicted
following, for example, jumping from a Figure 8.30 Bruising to extensor aspect of left arm – raised to
ward off impact from baseball bat. Figure 8.29 Defence injuries to right hand caused by knife. 92 8
Assessment, classification and documentation of injury height or under a train. There may be no specific
features to the injuries that identify them as selfinflicted. Self-inflicted bite marks may occasionally be
seen on the arms of an individual who claims to have been assaulted or blunt force injuries to the head
or other parts of the body. Abrasions might be created by using objects such as abrasive pads to
fabricate injury. Self-inflicted incised or stabbing injuries, however, frequently show specific patterns
that vary depending on the aim of the individual. In suicidal individuals, self-inflicted sharp-force injuries
are most commonly found at specific sites on the body called ‘elective sites’; for incised wounds these
are most commonly on the front of the wrists and neck, whereas stabbing injuries are most commonly
found over the precordium and the abdomen. In individuals who only desire to ‘self-harm’ or mutilate
themselves, the site can be anywhere on the body that can be reached by the individual (Figure 8.31).
Generally, the eyes, lips, nipples and genitalia tend to be spared. The other features of self-inflicted
injuries lie in the multiple, predominantly parallel, nature of the wounds and, in suicidal acts, the more
superficial injuries are referred to as ‘hesitation’ or ‘tentative’ injuries (Figure 8.32). The forensic
practitioner has an important role in the evaluation of the nature and pattern of injuries that might be
self-inflicted. In the absence of an admission of self-harm from an individual, it may be possible to come
to a view as to whether injuries are likely to have been self-inflicted if the characteristics listed in Table
8.1 are considered. Some or all of these characteristics - commonly inflicted by some form of
implement, such as a knife or a nail, may be present, but it is important to note that only some, and
rarely all, may be present in an individual case. The absence of a particular feature listed does not
preclude self-infliction; neither does its presence necessarily imply self-infliction. In some difficult cases,
it may not be possible to exclude assault, and evidence of self-harm, rather than assault, must come
from alternative sources, such as other witnesses. The staging of assault or injury may also involve other
individuals complicit in the process. In such a setting, injuries that are unusual as ‘self-harm’ injuries (e.g.
black eyes or deep abrasions) may have been inflicted by an accomplice. In such cases the detail of the
accounts given (or (a) (b) Figure 8.31 (a) Multiple linear burn marks (caused by heated knife blade
applied to the skin) – note healed lesions between acute lesions. (b) Multiple incised wounds to forearm
– note different ages of scars. Figure 8.32 Multiple new incised wounds with smaller and more superfi
cial tentative injuries (arrowed). 93 Torture not given) can be crucial in determining the actual course of
events. ■ Torture Article 3 of the European Convention on Human Rights states that no-one shall be
subjected to torture or to inhuman or degrading treatment or punishment. Unfortunately, such
treatment and punishment is still widely found throughout the world. Forensic physicians and
pathologists may be asked to assess individuals claiming torture or human rights abuse. Such
assessments can be complex and it may be necessary to assess and interpret physical findings for which
there may be a number of explanations. The doctor’s role is to assess these finding impartially. In order
to make an assessment for physical evidence of torture a structured examination must take place, which
involves the history, the medical history and then the physical examination. The physical examination
must involve systematic examination of the skin, face, chest and abdomen, musculoskeletal system,
genitourinary system and the central and peripheral nervous systems. Specific examination and
evaluation is required following specific forms of torture which include: beatings and other blunt
trauma; beatings of the feet; suspension; other positional torture; electric shock torture; dental torture;
asphyxiation; and sexual torture, including rape. Specialized diagnostic tests may be required to assess
damage (e.g. nerve conduction studies). The history taking should include direct quotes from the victim,
establishment of a chronology, where possible backing it up, for example with old medical records and
photos. A summary of detention settings, and abuses, must be obtained with details of the conditions
within those settings and methods of torture and ill-treatment. Attention must also be paid to, and may
require specialist assessment of, the psychological status of the victim. Specific torture techniques that
may be described include: Table 8.1 Some characteristics that may be associated with self-infl icted
injury Characteristic Additional Comments 1. On an area of the body that the individual can access
themselves Injuries in sites less accessible (e.g. the middle of the back) are less likely to have been self-
infl icted 2. Superfi cial or minor injury Severe self-infl icted injuries may also be caused, particularly in
those with psychiatric disorder 3. If there is more than one incised wound, they are of similar
appearance, style and orientation to one another (e.g. parallel with each other) Typically, self-infl icted
sharp force injuries are more superfi cial, numerous and similar to each other than those sustained in an
assault, where the natural reaction of the injured person is to avoid repeated injury 4. If there are other
types of injury (e.g. scratches, cigarette burns) these are also of similar appearance, style and orientation
to each other As above – multiple superfi cial, and relatively trivial injuries that are similar in nature and
extent to each other should raise the possibility of self-infl iction 5. Injuries grouped in a single
anatomical region As above 6. Injuries are grouped on the contralateral side to the patient’s handedness
A right-handed person will tend to harm themselves on the left side of the body 7. Tentative injuries
Smaller or lesser injuries grouped with the main injuries are termed ‘tentative’ or ‘hesitation’ marks,
where initial attempts at injury have been made 8. Old healed scars in similar sites May indicate
previous attempts at self-harm 9. Scars of different ages in similar sites May indicate repeated previous
attempts at self-harm 10. Slow-healing injuries Persistence of wounds that would otherwise have been
expected to heal, in the absence of any other factors 11. Psychiatric and related issues (such as eating
disorders, drug and alcohol misuse) There may be an increased incidence of self-infl iction with such
conditions 12. Possibility of self-infl icted injuries created to stage a crime These may lack many of the
features referred to above. 94 8 Assessment, classification and documentation of injury ■ beating of the
soles of the feet (falanga, falaka or bastinado; Figure 8.33) ■ amputation (Figure 8.34) ■ positional
torture – e.g. cheera (legs stretched apart) or Parrot’s Perch (wrists tied over knees – a pole placed
under the knees) ■ suspension – e.g. Palestinian hanging (arms and wrists tied and elevated behind the
back; figure 8.35), which can result in disruption of shoulder joint complexes and subsequent deformity.
■ electrical burns (Figure 8.36) ■ wet submarine – immersing the victim’s head in a container full of
water until the person almost drowns ■ dry submarino – placing the victim’s head inside a plastic bag
until nearly suffocated. Each of these may have short and long-term sequelae. It is important to
recognize that there may be no physical evidence of torture. Where scars or marks are present it is
important, for the credibility of the examination to distinguish between alleged torture scars and
injuries and non-torture scars and injuries. Istanbul protocol In order to address the issues of torture
and human rights abuses it is important that there are effective ways of documenting and comparing
findings. The Istanbul Protocol is the shortened term to describe the Manual on Effective Investigation
and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, a set
of international guidelines for documentation of torture and its consequences. It became a United
Nations official document in 1999 and provides a set of guidelines for the assessment of persons who
allege torture and ill-treatment, for investigating cases of alleged torture, Figure 8.33 Bruising to feet
caused by repeated blunt impact to feet – falanga. Figure 8.34 Amputation of right thumb as a form of
torture. Figure 8.35 Visible abnormality subsequent to joint disruption after Palestinian hanging. Figure
8.36 Electrical burns – scarring to scrotum as a result of application of electrodes. 95 Documentation of
injury or marks of injury and for reporting such findings to the judiciary and any other investigative body.
It is the most appropriate means by which robust evidence can be presented in a standardized manner
to the relevant authorities. Interpretation of findings regarding scars or marks is undertaken using the
following gradation: ■ Not consistent: could not have been caused by the trauma described ■ Consistent
with: the lesion could have been caused by the trauma described but it is nonspecific and there are
many other possible causes ■ Highly consistent: the lesion could have been caused by the trauma
described, and there are few other possible causes ■ Typical of: this is an appearance that is usually
found with this type of trauma ■ Diagnostic of: this appearance could not have been caused in any way
other than that described. ■ Documentation of injury or marks of injury There is a great temptation for
doctors and other healthcare professionals to use medical terminology to imbue a sense of
professionalism and expertise to reports and statements. This approach is generally not helpful, either
to colleagues attempting to interpret their meaning or to courts unless a concurrent explanation in lay
terms is provided. Forensic pathologists have to use all available information, from police, from
witnesses, from medical records, from family and many other sources to determine what may or may
not have caused fatal injury. Forensic physicians dealing with the injured living person may be able to
get a history directly from that person. If it is possible to take a history, then the relevance of factors
such as those listed below should be considered: ■ Time of injury or injuries ■ Has injury been treated
(e.g. at hospital or at home)? ■ Pre-existing illnesses (e.g. skin disease) ■ Regular physical activity (e.g.
contact sports) ■ Regular medication (e.g. anticoagulants, steroids) ■ Handedness of victim and suspect
■ Use of drugs and alcohol ■ Weapon or weapons used (if still available) ■ Clothing worn This
information should be easily obtainable and documented in the contemporaneous medical notes. There
is often an ‘evidence gap’ for those seriously injured, and who require resuscitation and immediate
surgery or ventilation, when compared with relatively minor interpersonal assaults, where the
complainant can give a full account and injuries can be documented, and the deceased, who will have a
post-mortem examination carried out by a forensic pathologist. The duty of care in the critically injured
rightly outweighs the need to document injury accurately, or to retrieve crucial evidence, and lack of
forensic skills mean that often hugely important evidence (e.g. nature of injury or important trace
materials) is lost. There is a clear argument for (1) increasing the level of forensic skills of those involved
in the care of the severely or critically injured or (2) have available forensic physicians who can (with the
consent of the clinical teams) gather evidence at the earliest opportunity. The following characteristics
should be recorded wherever possible for each injury: ■ Location (anatomical – measure distance from
landmarks) ■ Pain ■ Tenderness ■ Reduced mobility ■ Type (e.g. bruise, laceration, abrasion) ■ Size (use
metric values – use a ruler, do not estimate) ■ Shape ■ Colour ■ Orientation ■ Age ■ Causation ■
Handedness ■ Time ■ Transientness (of injury). The recording of such information in the clinical setting
should ideally be in three forms. First in a written form, appropriately describing the injury, second as a
hand-drawn body diagram and, idea lly, to supplement the first two, in digital image form. Such
documentation will ensure that the opportunity for proper interpretation is maximized. Thus any clinical
notes should: record the appropriate history; record accurately and clearly all findings – positive and
negative; record legibly; summarize findings with clarity; use consistent terminology; and interpret
within the limits of your experience. 96 8 Assessment, classification and documentation of injury If you
cannot, or should not give opinion on your clinical findings, state this clearly. Forensic pathologists must
document and record all injuries identified at post-mortem examination in detail, sufficient to enable
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